Saturday, July 7, 2012

Good Healthcare is a Symphony


Good health care is like a fine symphony.  Different professionals and different skills must work in concert to create a result that is much bigger than the individual components.    Here are two versions of a well-known anecdote in the classical music world that has been repeated in many versions over the years.  It tells the story of an efficiency expert enlisted to investigate a symphony orchestra.

Version 1

 He reported: "I found hidden unemployment. At least seven employees played the very same movements, on violins, throughout an entire piece.  On the other hand, the employees in the wind and percussion sections sat through extended periods of a concert without moving a muscle or playing a thing. I also discovered there were entire parts that musicians played over and over, for no reason.  Most of the employees appear to be unskilled as the management has to employ a man, full-time, to wave his arms around and signal to them what to play, when to stop, at what speed, and even at what volume.”

All of this, forced the efficiency expert to come to the conclusion an orchestra is a wasteful institution; it is neither efficient nor profitable; its output may be categorized as "arty and impractical".

Version 2 – A specific report on Schubert’s Unfinished Symphony

  1. For a considerable period, the oboe players had nothing to do. Their number should be reduced and their work spread over the whole orchestra, avoiding peaks of inactivity.
  2. All 12 violins were playing identical notes. This seems to be unneeded duplication, and the staff of this section should be cut. If a volume of sound is really required, this could be accomplished with the use of an amplifier.
  3. Much effort was involved in playing the 16th notes. This appears to be an excessive refinement, and it is recommended that all notes be rounded up to the nearest 8th note. If this were done, it would be possible to use para-professionals instead of experienced musicians.
  4. No useful purpose is served by repeating with horns the passage that has already been handled by strings. If all such redundant passages were eliminated then the concert could be reduced from two hours to twenty minutes.
  5. The symphony had two movements. If Mr. Schubert didn't achieve his musical goals by the end of the first movement, then he should have stopped there.

In light of the above, one can only conclude that had Mr. Schubert given attention to these matters, he probably would have had time to finish the symphony.

Why do I relate these stories in a discussion of health care?  

In many ways, the move to managed care has been told by these anecdotes.  In the move to make health care more affordable, which is a wonderful goal as it increases access to health care, we have tried to make individual doctor visits more efficient and we have succeeded.  Unfortunately, much of the richness of the physician leading a team and coordinating an effort with the goal of creating a wonderful result greater than the individual pieces has been lost in the process.  As physicians are not rewarded for coordination and in many ways are even discouraged financially from working together the doctors become nothing more than technical experts in their own scientific fields.  Even family physicians who are supposed to be the paradigms of ongoing coordinated care, are unable to do all that needs to be done to assist, coordinate and support those traveling through the complex medical system.  Instead they are expected and trained to see large numbers of patients per day with “simple” illnesses and to triage those who are sicker to specialists. 

But in our complex medical world, there are no simple illnesses.  Every illness has emotional, financial, and social factors.  The mother with small children and limited income who has asthma and needs a chest x-ray and pulmonary function tests needs to understand how to pay any copayments and be able to afford those co-payments, needs a way to schedule the tests, needs a person to watch her children while she goes for the test, and needs help understanding the risks and benefits of the medications that she will have to purchase and take.  She needs someone to help her find the way to communicate all this to her family, who depend on her, and needs help dealing with the stress and fear that accompanies it.  Yet we now have no concert master or conductor.  The primary care doctor has no time, and is not paid to do all this.

I am enough of a traditionalist to believe that a good physician should make the best “conductor” of this symphony although I also know that strong health professionals trained in other disciplines such as nursing, psychology and social work can also play that type of role. It is less a matter of formal degrees and more a matter of communication and coordination skills and resources.  In the best of all possible worlds, a doctor would team with a professional communicator/coordinator/supporter (in Accolade terms a Health Assistant) to give the patient the best chance of having health care that resonates as a fine symphony.  A doctor would then be able to still be relatively efficient while giving the patient everything he or she needs. 

We need both scientific medicine and a symphony like beauty and elegance in the delivery of that medicine.  Until that happens, managed care, of which I am a part, will capture efficiency at the expense of truly caring for those in need.  Here at Accolade, we are committed to providing the humanity that everyone needs in a way that creates cost savings while enhancing the important element of caring.